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Could A Holistic Approach to Mealtimes Help Dementia Sufferers?
Dementia is one of the most pressing challenges for the care of older people. It’s also a major contributor to disability and dependence. Risks for, and prevalence of, malnutrition and dehydration are high in older people, even higher in older people with dementia. So both dementia care and nutrition are crucial areas of exploration for research.
But Which Interventions May Be Helpful for People with Dementia?
We are fortunate to have two recent reviews that have looked at this very subject. Two EDWINA (Eating and Drinking Well IN dementiA) systematic reviews, undertaken by researchers at Norwich Medical School-University of East Anglia. They aimed to assess the effectiveness of interventions to improve, maintain or facilitate food and drink intake, nutrition and hydration, in people with cognitive impairment or dementia across all settings, levels of care and support, types and degrees of dementia (including mild cognitive impairment).
Interventions to support older people around eating and drinking vary. Together by systematically reviewing existing research on all interventions aiming to improve, maintain or facilitate food or drink intake (directly or indirectly) in adults with dementia of any stage and in any setting, they provide us with the underpinning research evidence in this area. And systematic reviews are really key to being able to summarise the existing research on a topic. The term covers a whole process of specifying a clear research question, systematically searching for all relevant and valid studies and reporting the overall findings.
Effectiveness of Interventions to Directly Support Food and Drink Intake
Direct interventions (alone or as part of multicomponent interventions) looked at in the reviews include:
- Provision of oral nutrition supplements (ONS)
- Food and drink modification
- Dysphagia management (management of swallowing problems)
- Eating and drinking assistance and/or
- Supporting the social element of eating and drinking
The researchers looked at 43 direct interventions. Most interventions occurred within residential institutions of various types. Included studies were mostly small (5 to 515 participants, with only 7 having more than 100 participants). The quality was poor.
Oral nutritional supplementation studies (ONS with usual food compared to usual food alone), suggested small positive short term, but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing some limited evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality, provided consistent suggestion of improvements in aspects of quality of life.
As this systematic review did not find sufficient high quality evidence to state that any particular intervention was clearly effective, or clearly ineffective, these interventions require further research. Interventions that were classified as promising by the authors and may warrant further high quality studies were classified by the researchers, and illustrated below.
|Increase weight||Oral nutrition supplements, specialised modified diets, individual mealtime assistance, shared mealtimes with staff|
|Increase food intake||Finger food provision, mealtime/between mealtime feeding assistance, specialised dysphagia diets|
|Improve quality of life||Reminiscent cooking sessions|
|Meaningful engagement with food / drink||Eating with carers, family style meals, resident involvement in cooking, preparation, conversing, eating and clearing|
Effectiveness of Interventions to Indirectly Support Food and Drink Intake
It is likely that it is not just what people eat and drink that is important for their nutritional wellbeing. Engagement and quality of life, but also how and where they eat and drink. Atmosphere, physical and social support offered, understanding of formal and informal caregivers, and levels of physical activity enjoyed.
Therefore a second review by the research team systematically assessed the effectiveness of 56 indirect interventions. This included environmental, educational, behavioural, exercise and multicomponent interventions to affect food/drink intake or experience indirectly.
Indirect interventions (alone or as part of multicomponent interventions) looked at in the reviews included:
- Altering dining environment or food service
- Providing education or training for people with dementia or their care-givers
- Behavioural interventions
- Exercise programs
- Combinations of these in multicomponent interventions
As with the direct interventions, for indirect interventions, the studies were small and of poor quality – and there were no clearly effective, or clearly ineffective, interventions. Promising interventions highlighted by the authors in this review meriting further higher quality research focused on a holistic approach to mealtimes and include mealtime music, some lighting and contrast interventions to improve visual cues, constantly accessible snacks and longer mealtimes, education and support for formal and informal caregivers, multisensory exercise and multicomponent interventions.
Eating and Drinking for People with Dementia May Present Challenges to Carers
Despite no clear evidence of effectiveness, people with dementia regularly have to deal with problems around eating and drinking, including needing to be fed, food refusal, and swallowing difficulties which present challenges for their carers. For this reason, despite the lack of firm evidence, caregivers may find it useful to read about the different interventions that have been tested, as this may help to identify potential interventions that may be appropriate for service users with dementia in particular settings.
However high quality research is clearly needed to build on the existing research summarised in this review, to help understand what types of interventions are effective in supporting adults with dementia to eat and drink well, and to remain actively engaged with food and drink.
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